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Classifying Causes of Death in the Mortality Collection Christine Fowler Team Leader Mortality Collection Ministry of Health August 2010 Overview ¾Overview Mortality Collection ¾Sources of information ¾Classifying causes of death ¾ICD versions used for mortality ¾World Health Organization (WHO) classification updates ¾Coding issues Slide 2 Mortality Collection ¾Holds data from 1988 onwards ¾BDM death registrations=core dataset ¾Approx 29,000 deaths each year ¾NHI numbers on all records ¾Causes of death coded in ICD-10-AM ¾Data collected & published by year of death registration Slide 3 Staffing ¾Team Leader ¾Administrators x 2 ¾Clinical Coders x 6 Mortality Clinical Coders require an excellent knowledge of diseases and disease progression as well as clinical coding expertise Slide 4 Sources of information Primary data sources include: ¾BDM death registrations ¾Medical certificates of cause of death ¾Coroners’ notifications & final findings ¾Postmortem reports Slide 5 Demographic information ¾Names & alternate names ¾National Health Index (NHI) number ¾Date of birth & date of death ¾Address ¾Ethnicity ¾Place of birth ¾Place of death ¾Occupation ¾Maori descent Slide 6 Demographic coding ¾Ethnicity (up to 3 codes recorded) ¾Country of birth ¾Domicile code (Area Health Unit) ¾Mesh block ¾Facility in which died (if died in hospital) Slide 7 Medical Certificate of Cause of Death Cause of death I Disease or condition directly leading to death Antecedent causes, stating underlying condition last a)________________ Approx interval between onset & death due to (as consequence of) b)_______________ due to (as consequence of) c)________________ II Other significant conditions contributing to death Slide 8 Classifying underlying cause of death (U/C) WHO definition: “a) the disease or injury which initiated the train of morbid events leading directly to death, or b) the circumstances of the accident or violence which produced the fatal injury” Classifications used: ¾ ICD-10-AM, 6th Edition codes ¾ ICD-10 (WHO) Rules & guidelines for mortality coding Slide 9 Classifying contributing causes of death ¾ Cancers (C00-C96) + (D45-D47) ¾ Selected other causes, e.g. diabetes mellitus, obesity, alcohol & drug abuse/addiction ¾ Injuries (S00-T98) ¾ Complications of Medical & Surgical Care (Y40-Y84) Other ICD coding: ¾ Place of accident/incident (Y92.) ¾ Activity – Sports/recreation/work (U50-U73) Slide 10 Other injury-related information ¾Alcohol & drug involved indicators ¾Blood alcohol level (mg/100mls) ¾Work-relatedness ¾Drug & Injury Details (free text field) Note: These variables are only collected for deaths due to external causes Slide 11 Other variables collected ¾Death certifier code (doctor, coroner) ¾Postmortem code ¾Source of death information code (News Media, WSNZ, LTSA etc) ¾Document status code (Doc status 4 = Awaiting coroner’s finding) ¾Clinical Notes – free text information about circumstances surrounding death Slide 12 ICD versions ICD version used by year of death registration: ¾ ICD-9-CM-A 1988-1999 ¾ ICD-10-AM, 2nd Edition 2000-2007 ¾ ICD-10-AM, 3rd Edition Activity codes used from 2003-2007 ¾ ICD-10-AM, 6th Edition 2008 onwards Slide 13 WHO classification updates Updates to the ICD-10 classification and mortality coding rules are ratified at the annual WHO-FIC meetings 2006 major mortality rule change accidental poisoning in drug/alcohol dependency now coded to X40-X49 Accidental poisoning as underlying cause Pre-2006 underlying cause was coded to F10-F19 in the Mental & behavioural disorders chapter Slide 14 Quality assurance Assisted by: ¾ Coded by one coder, checked & input by another ¾ Mortality Medical Data System (MMDS) software to check U/C code selection ¾ International Mortality Forum email discussion group to obtain other opinions ¾ Annual in-house coding audit ¾ Feedback from WHO reporting Slide 15 Coroners Act 2006 The Coroners Act came into effect on 1 July 2007 with the following positive outcomes: ¾Investigations held sooner ->more timely findings ¾Chief Coroner is an advocate for more timely & consistent coronial data ¾Electronic notifications & findings to MoH ¾More postmortem reports received Slide 16 Provisional cause of death coding ¾ Provisional U/C code is assigned until final coroner’s finding received ¾ R99 Other ill-defined & unspecified causes of mortality assigned if no information about cause is available ¾ X59 Exposure to unspecified factor assigned if injuries recorded but not the cause of the injuries ¾ U/C and other coding is reviewed & updated when the coroner’s findings is received Slide 17 Additional sources of information about cause of death ¾ Coroner’s notification – interim cause ¾ NMDS hospitalisation data ¾ Land Transport NZ (LTSA) ¾ Water Safety NZ ¾ New media reports – Internet ¾ NZ Cancer Registry ¾ Letters from certifying doctors Slide 18 Awaiting coroners’ findings As at 24 August 2010 Document status 4 Awaiting coroner’s finding 2008 = 411 2009 = 1543 (U/C provisionally coded on all records) U/C R99 + X59 + Document status 4 2008 = 16 2009 = 197 (No cause information, awaiting coroners’ findings) Slide 19 Mortality coding challenges ¾ Injuries listed but no external cause ¾ PM lists only apparently minor conditions but states “..these were unlikely to have been the cause of death” ¾ SIDS & SUDI – pathologists & coroners moving away from using ‘Sudden Infant Death Syndrome’ in favour of ‘Sudden Unexpected Death in Infancy’ ¾ Coding ‘intent’ for self-inflicted deaths Slide 20 WHO ICD-10 mortality rules ICD-10, Volume 2 Instruction Manual – a couple of important U/C selection rules 4.1.9 Modification Rule A ‘Where the selected cause is ill-defined and a condition classified elsewhere is reported on the certificate, reselect the cause of death as if the ill-defined condition had not been reported, except to take account of that condition if it modifies the coding’. Slide 21 Possible/Probable/Apparent 4.2.14 Expressions indicating doubtful diagnosis ‘Qualifying expressions indicating some doubt as to the accuracy of the diagnosis, such as “apparently”, “presumably”, “possibly”, etc. should be ignored, since entries without such qualification differ only in the degree of certainty of the diagnosis”. Slide 22 SIDS, SUDI, accidental asphyxia Example 1, Age 4 months (a) Direct cause of death Undetermined (c) Underlying condition Nil (d) Other significant conditions Unsafe sleeping environment: Co-sleeping with adult; Exposure to smoking adult before and after birth; Consumption of alcohol by co-sleeping adult. Postmortem failed to reveal any medical condition that may have caused death. Cause of death – SIDS, category II (co-sleeping) U/C code R95 Sudden Infant Death Syndrome Slide 23 SIDS, SUDI, accidental asphyxia contd Example 2, Age 2 months (a) Direct cause of death Sudden Unexpected Death in Infancy (SUDI) (b) Antecedent cause Possible accidental asphyxia Unsafe sleeping environment Bed sharing with adult Prone sleeping U/C code W75 Accidental suffocation in bed Slide 24 SIDS, SUDI, accidental asphyxia contd Example 3, Age 5 months (a) Direct cause Possible accidental asphyxia while sleeping in adult bed with pillow (b) Antecedent cause Chronic lung disease of prematurity requiring continuous oxygen (d) Other significant condition Congenital heart disease (surgical repair) with pacemaker U/C code W75 Accidental suffocation in bed Slide 25 SIDS, SUDI, accidental asphyxia contd Example 4, Age 4 months (a) Direct cause Sudden Infant Death Syndrome (c) Underlying cause Nil (d) Other significant condition Gastroenteritis causing clinical dehydration U/C code A099 Gastroenteritis and colitis of unspecified origin Slide 26 Self-inflicted deaths - intent ¾Intent still often unreported so additional follow-up required with CSU ¾If deceased was psychotic at time of death intent may be reported like this “…but whether she was then capable of forming an intent to take her own life, knowing the nature of her actions and their consequences, the evidence does not enable the court to say.” Coded to ‘undetermined intent’ Slide 27 Questions? Can be addressed to: Christine Fowler Email: [email protected] Phone: (04) 816 2864 Mortality data requests email to: [email protected] Slide 28 Vital statistics “How the people (of England) live is one of the most important questions that can be considered; and how – of what causes, and at what ages – they die is scarcely of less account; for it is the complement of the primary question teaching men how to live a longer, healthier, and happier life.” William Farr, MD Life and Death in England 1885 Slide 29